As of 21 July 2008, responses were received from 141 out of 152 PCTs (overall response rate of 93%). However, the responding PCTs did not always disclose information for all of the questions.
How this fits in
Several surveys on the use of alternative providers of medical services (APMS) in England suggest that, although GP-led providers are usually successful in winning contracts, private commercial companies have begun to establish a presence. This study shows that, increasingly, APMS contracts are not only being awarded to large, for-profit multinationals, but are also subject to no competition. This is the first published study to systematically identify the providers of APMS tenders, competing bidders, the services provided, patient numbers, and the length and value of contracts.
Availability of information on APMS contracts
Number of PCTs awarding APMS contracts
shows that as of July 2008, of the 141 PCTs that responded, 49 had awarded one or more APMS contracts, giving a total of 71 APMS awarded contracts. Sixty-six contracts were out to tender. Of the 49 PCTs, only 41 provided data on contract value; in the South West and North East regions just a third of PCTs awarding APMS contracts supplied such data.
Number of APMS contracts awarded and out to tender by SHA region in England (by July 2008).
Patient numbers, contract value, contract duration, and services
Data detailing the number of patients covered by contracts, as well as contract value, duration and the services covered are outlined in .
Patient numbers, value, duration, and services under APMS contracts.
For 14 of the 71 (20%) contracts, the patient numbers were not disclosed or were not available (for example, if the contract was for a walk-in centre). Of those contracts for which there was information, patient numbers ranged between one (for a patient support programme) and several hundred thousand (for PCT-wide out-of-hours services). Half of all practices under APMS contracts had them for between 1000 and 5000 patients. The average practice size for those APMS contracts for which there was information on patient numbers (excluding out-of-hours services and the special case of the support programme for one patient) was 3206 patients. On the basis of the available information, it was calculated that 1.14% of the patient population were covered by APMS contracts (out-of-hours and walk-in services were excluded for this calculation).
For 30 of the 71 (42%) contracts the contract value was not disclosed. Of the 41 for which this information was disclosed, exact data are given for 33 contracts; the remaining eight only stated a range. Annual contract values ranged from £6000 (the above-mentioned patient support programme) to almost £12 million (out-of-hours services). Some PCTs released only the annual contract value, although others gave the value over the whole period of the contract. For 13 of the 71 (18%) contracts no information was disclosed on contract duration. The duration varied considerably from <1 year to being open ended. Almost one-third of contracts were for 5–6 years; some had break clauses or the option to extend. Due to the massive lack of data it was not possible to derive an estimate of the value of all APMS contracts.
The services contracted for under the APMS system do not usually differ greatly from General Medical Services (GMS) or Personal Medical Services (PMS) contracts and included essential, additional, and enhanced services. Nine contracts were for out-of-hours services, three included walk-in services, and seven were for specialist services, for example, for substance and alcohol misuse; services for asylum seekers, refugees, and persons who were homeless; or for prison health. Four contracts did not disclose which services were offered.
Typology of providers
Four categories of providers were identified (). Half of all APMS contract tenders were awarded to nationwide or multinational commercial companies (36 out of 71); 28 contracts to independent contractors, either set up by a single GP or in partnership; seven contracts went to so-called ‘social enterprises’ or community interest companies, that is, non-profit organisations; and two to a nurse-led PCT managed service. One contract was a hybrid case, shared by three different providers, of which one was GP-led and the other two were commercial.
Typology of APMS providers and availability of data on other bidders.
Competition and bidders
PCTs provided information on bidders for 30 of 71 contracts. Of those 30, 12 involved no competition either because the tender was waived or there was only one provider tendering for the contract ().
Ten of the 30 contracts for which there was information on other bidders were awarded to single-handed GPs or partnerships. In five of the 10 contracts there was no other bidder; in three cases it was in competition with other local GPs, non-profit organisations, PCT services, or NHS trusts; in only two practices did an independent GP beat commercial contractors to secure an APMS contract.
Information on other bidders was only received for five contracts won by non-profit organisations or PCT-managed services. In four of these instances, there was no competition with other providers because the tender was waived or restricted to the particular type of organisation. The authors were only aware of one case in which a non-profit organisation beat three commercial providers to win the contract.
Of the 36 practices that were awarded to a commercial company, there were data on bidders for just 14 contracts. In three of these 14 instances there was no other bidder, in two further cases there was competition among commercial companies only; the remaining nine contracts included other commercial companies, GP-led providers, non-profit organisations, PCT provider services, and NHS trusts as bidders.
lists the corporate providers of primary care in England identified from the survey and additional information on other contracts gathered from their company websites. From this a further 50 primary care contracts in England were identified; however, the authors do not know whether or not these contracts are APMS contracts.
Commercial providers of primary care in England, number and type of contracts, value and length.